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Applications Will Be Proressed`Nhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I r K APPLICATION <br /> ['p y� ��ice( (For Non-Transferable, Revocable, Suspendable) <br /> I'EJMP&WELL � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY W <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinanc No. 1862 anji,d the rules and regulations of the San Joaquin Local He lth tstrict. X <br /> Exact Site Address � R City/Town �� A�� <br /> Owner's Name S- " 02!1 erne-/ dpie/ Phone <br /> Address City <br /> Contractor's Name �l License# 1� "'�1 Business Phone <br /> Contractor's Address W 0` Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HD? Yes 1'' -- No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCr I v NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 14 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Ins,pied By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump MX — H.P. S' 0 <br /> PUMP REPLACEMENT: ❑ State Work Done (h <br /> PUMP REPAIR: ® State Work Done �Z4r'4WZ1 Q�I[F�F idni �J <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies 1he following:1 certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection or1 groutma and final inspection. <br /> Signed X& itle: ''^ Date: <br /> (Draw Plo lan on Reverse Side <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By 4w Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phas III Final Inspection <br /> Inspection By Date Inspection By � Date 42 r?G-2/f, <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> •0 <br /> FEE <]►,% L�s. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ 7779 13 toy 1 4191-7 <br /> Received by Date Receipt No. Permit No, Issuance Date Mai$ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,.CA 95201 <br />